Disseminated cytomegalovirus infection involving the skin in a patient with chronic renal insufficiency

Abstract

A 58-year-old male with chronic renal insufficiency, gouty arthritis and iron deficiency anemia of 10 years' duration was admitted to our hospital because of pneumonia. He was treated with amoxicillin-clavulanate and gentamicin. He also received a transfusion of 2 units of packed red blood cells because of anaemia (hemoglobin 7.7 g /dl). Skin rashes appeared on the tenth day after admission, starting from his lower limbs with progressive, upward extension. Visual inspection revealed scaly erythematous macules and papules over his buttocks and lower limbs ( Fig. 1).A skin biopsy was performed from the patient's left thigh. The histopathological examination revealed moderate upper dermal perivascular mononuclear cell infiltrates. The main finding was enlarged endothelial cells containing darkly stained intranuclear inclusions (owl's eyes) characteristic of cytomegalovirus (CMV) infection ( Fig. 2a). PAS staining revealed intracytoplasmic inclusions (Fig. 2b).Laboratory surveys for systemic involvement were carried out. Serum titers of CMV antibodies showed IgG 250 AU/ml (normal range 0 -15) and IgM 1.513 (a normal range of the index < 0.5). Blood culture failed to isolate CMV whereas urine culture revealed a positive finding. Throat culture disclosed an adenoviral infection. Using two primer sets from the immediate-early gene, the results of polymerase chain reaction (PCR) with serum, urine and paraffin block of skin specimen all detected specific CMV DNA amplicons (Fig. 3). 1 The sequences of the primers for PCR detection of CMV are revealed in Table 1. These data indicated its disseminated nature instead of a localized cutaneous CMV infection.Immunological profiles showed normal IgG, IgA, and IgE values, while IgM and C3 levels were decreased (IgM 53 mg / dl and C3 62 mg /dl). Test for antinuclear factor was negative. The CD4 /CD8 ratio was decreased. In our case CD4 /CD8 ratio was 0.57, and the normal ratio of CD4 /CD8 ranges from 0.95 to 1.53. HIV antibody was negative. Figure 1 Multiple scaly erythematous macules and papules distributed on the left lower limb

Viral diseases

“…360 371 No CMV inclusion bodies were present. 382 Infants with congenital infection with CMV may present with petechiae and blue-red macular or plaque-like (so-called 'blueberry muffin') lesions, in addition to neurological abnormalities. 372,373 The patients are usually immunocompromised, 363,374,375 a clinical setting in which mixed infections with other agents, particularly herpes simplex virus, may occur.…”